Documente Academic
Documente Profesional
Documente Cultură
Farid R. Talih, MD
Diplomate of the American Board of Psychiatry and Neurology
Psychiatry and Sleep Medicine
Assistant Professor of Psychiatry
Dept. of Psychiatry
AUBMC
SOMATOFORM DISORDERS
!One or multiple somatic complaints that cannot be
attributed to a medical condition, drug abuse, or a
psychiatric disorder.
!R/O factitious disorder or malingering.
they are extremely common they are from the people who have headaches , stomach aches
people are so invested in their disease that they wont let go of it so if you tell the patient your ok go check a psych they will take it in a bad way so when you
have multiple somatic complains that cannot be attributed to any condition like for example an alcoholic that wakes up with hangover everyday we think he has
a headache
if i think that ophtalo have implanted a cam in my eye and can see what i see this is not somatoform this is psychosis or schizo
somatomform are unconsciously being manifested and not on purpose this is the hallmark diff btw factious and amlingering that is obv faking for a reason
(hand hurts so i cant move it this is cz i dont want to work
facticious is faking it for psych reasons i want to be sick i want attention
Somatoform Disorders
!Somatization Disorder
!Hypochondriasis
!Body Dysmorphic Disorder
!Conversion Disorder
!Pain Disorder
!Undifferentiated Somatoform Disorder
!Somatoform Disorder NOS
conversion disorder is
pseudoneurological.
neurologists deal with
conversions.
pain disorder are very
problematic lead to
addiction i keep on
going to the dr because
of the pain and
eventually i end up with
high doses of addictive
medicine and get stuck.
common manifestation
is that they are
unconsciously
triggered as a
manifestation of
repressed issues or
desires or
manifestations of
certain fear: females
who had traumatic
sexual experiences as
young women: develop
dosmatic symptoms
related to genital area.
pelvic pain
dyspareunia ,vaginism
us
SOMATIZATION DISORDER
!Multiple somatic complaints (at least 4 pain, 2 GI, 1
sexual, and 1 pseudo-neurological)
!Multiple medical work-ups are non-revealing
!Disruption of usual or daily functional activities
!Significant psychological distress
!known as Briquets syndrome
!Prevalence 0.1-0.2%; F/M is 5:1.
!onset before age 30 and lasts for years
!Co-morbidity with anxiety and depression/personality
traits or disorder
in some children you can see it he saw girl was started with pain med at 12, because of
migraines. she is now an addict. was very mistreated, abused, the only way toe xpress
herelf sas a child was pain and it became her identity.
need to take away the fear concept. these people insted of talking about their problems they
talk about their pain. they invest everything in the pain. see different doctors, travel, do
everything but never get better. more common in females. could be related to more
psychosocial stress in females. correlates directly with being repressed. so women have
less areas to epxress themselves academically socially and even sexually so lots of
repression , usually starts in the mid 20s and lasts for years it could be life long
SOMATIZATION DISORDER
ETIOLOGY
!Psychosocial Factors
it maybe to get something or to avoid something we play the sick role and
being sick helps sometimes. some adults who cant cope anymore tend to act
sick u see it in women with alot of sexual repression and some people with
sexual identity issues and cant achieve their sexuality a young man who has
to suppress his own sexuality
!Social communication
soem adults take the sick role. seen in some people with sexual identity issues and cant achieve
!Avoid obligation/sick role? their identity. homosexual cant express himself.
!Express emotions or symbolize a feeling
!Substitution for repressed impulses
!Biological Factors
but its mostly a psychological issue. poeple statr making stuff up.
inflammation
SOMATIZATION DISORDER
!Clinical Features
it travels and can come and go hallaa weje3ne batne next week rasse
!Differential diagnosis
!R/O medical problem
!Depression/ Generalized Anxiety Disorder/ Schizophrenia
!Panic Disorder
!Other somatoform disorders
chronic progressive difficult to treat and it can be really disabling and when u have more stress you have more pain
SOMATIZATION DISORDER
!Course and Prognosis:
!Chronic and recurrent
!Patients always seek medical attention
!Symptoms increase with psychological distress
!Treatment:
frequent visits with one person who coordinates with the others and
regardless if your good or not you have to come and see me every
month. avoid unneeded testing and start telling the patient that
their symptoms are related to emotional and psychological stress
CONVERSION DISORDER
neurological or pseudoneurological sudden loses with la
belle indiference, casual not freaking out.if i suddenly
cannot see anymore i freak out while people with
conversion disorder show up to the ER super chill. wake
up, cant see, but chill about it.
CONVERSION DISORDER
!Etiology
freud. if suddenly cannot see, could be because saw something very horrible and want someone to ask me
about it. if can't speak: selective mutism or pshycongeic dysphonia.some people cannt speak anymore
but if you ask them to whistle they can blindness most common. and the most common one is the
nonepileptic seizures
!Clinical Features
!Paralysis, blindness, and mutism are the most common
!Sensory or motor symptoms
we no longer say pseudoepileptic
!Pseudoseizures
!Other associated features
non epileptic seizures.
CONVERSION DISORDER
!Differential diagnosis
!15-65 % may have a concomitant or previous history of a
neurological disorder
!25-50 % may end having a medical or neurological disorder
!Neurological disorders
the catch is that many of these people end up having
!Depressive/anxiety disorders
neurological diseases 20% of people with non epi seizure
end up having some type seizures
!Schizophrenia
!Other somatoform disorders
!Factitious disorder
!Malingering
CONVERSION DISORDER
!Course and Prognosis
!Conversion symptoms resolve quickly in the majority of cases
!Under stress symptoms may recur in 25% of patients with
conversion disorder
!Good prognostic factors: sudden onset, short duration, good
premorbid history, clear stressful precipitant, and absence of
medical or psychiatric illness
it is different than somatization. comes quickly and goes away quickly. come to the ER blind we give you an injection of valium you are cured
you go home w meshe l 7al its not going to keep on happening like somatization . can be reproduced by suggestion. you can elicit it by showing
and talking to them but you cannot elicit somebody to a seizure by talking to them
spontaneous remission very common.
!Treatment:
!Spontaneous remission is common
!Psychotherapy can facilitate
the resolution
can help
!Medications: Amytal or lorazepam (anxiolytics)
it is one of the rare things in which hypnosis
!Hypnosis can
help
in general hypnosis is overrated, its just a
stage of heightened relaxation but it does help.
if they came with nonepileptic seizure do a prolactin test should be low or an EEG they
should lack a postictal stage maintain therir ocnciousness non cyanotic or incontinent and
quickly recover
people who have lower .. paralysis put your hand under the good leg and tell them try to lift the bad leg if they are
trying but truley paralyzed you will feel them pushing on your hand if there is no pressure on your hand then they are
not trying to lift their leg
HYPROCHONDRIASIS
!Preoccupation with fear of having a serious illness/
misinterpretation with bodily sensations
!Very common in general medical workers
!Commonly starts at age 30-40
!No effect of sex, marital status, education, or
socioeconomic status
unlike conversion
different from the med student syndrome starts in the 30-40 they think if a little dot appears then it is cancer so go and check it comes in people who are anxious and
obsessive this can happen in people of higher SES and with more access to info. many people come with handouts and prints if you dont they get very upset
!Etiology:
!More sensitive and less tolerant of discomfort
!Induction of sick role
!Association with depressive and anxiety disorders
!Psychodynamic: way to express repressed anger;
defense against guilt
it is sometimes psychodynamically imp, it is a freudian interpretation it is to express repressed anger a defense
mechanism against guilt it is not delusional they do respond to reassurance they go to the Dr they tell them it isnt
cancer we are fine until we find another theory but if u are delusional you are not going to be reassured you will not
believe the Dr and think that he wants you to die from skin cancer
HYPROCHONDRIASIS
!may change from one illness to another
!Not delusional and not restricted to appearance
!Duration is at least six months
!Transient hypochondriacal states can happen under stress/
sometimes reinforced by familys reaction or physicians
they do respond to
reassurance so its not
delusional. if delusional,
wont be reassured.
!Differential Diagnosis:
!Somatoform disorders
!Depressive and anxiety disorders
!Schizophrenia and other psychotic disorders
!Factitious disorder and malingering
HYPROCHONDRIASIS
!Course and Prognosis
!Episodes last for months to years with equal time of relief
!Level of stress can affect the course
!1/3 to may improve markedly
!Good Prognostic factors: anxiety and depression that respond to
treatment; absence of medical conditions or personality disorder;
better socio-economical situation
its not easy to treat half of them will suffer for a very long time and the episodes will last for years and people get second and third opinionstry
!Treatment
!Regular appointment/avoid unnecessary tests/
strategies to cope with stress
!Meds for associated anxiety/depression
!Group psychotherapy
try to psychoeucate the patietn, putting hypochondiracs together can help.
BODY DYSMORPHIC
DISORDER
more common among younger female and unfortunately due to many psychological stressors in life this is how they percieve themselves men have inflated self image
not delusional
!Serotonin
!social pressure
!psychodynamic
see it it people whose families are image oriented: mother criticizes appearance of the daughter
avoid using surgery because these people will become addictive to the surgery these patients will always be unsatisfied costumers
!Treatment
!Using medical or surgical interventions to deal with
the alleged defect is unsuccessful
!SSRI are effective in 50% of cases
!Case reports of good results with TCA, MAO
inhibitors, and pimozide
due to the OCD component
this is reverse body dysmorphia seen in the subculture of body builders or fitness enthusiasts they consume
alot of drugs and proteins and they are convinced that they are small and weak and not big enough LOL:P
reverse epilepsia
reverse body dysmorphia: consume massive amoutns of drugs and exercise, and convinced they are small, weak and not big
enough. conveptualized as a reverse anorexia.
PAIN DISORDER
!Pain in one or more body sites
!M/F is
!Onset peaks at age 40-50 years
!Possible genetic inheritance
!Comorbidity with substance abuse and depressive &
anxiety disorders
middle aged of life
possibly learned behavior (form mother). very comorbid with substance abuse.
substance abuse is mostly iatrogenic doctors are giving medications and
more and more pain medicines but this doesnt work . pain is not in leg.
could be a manifestation of severe interpersonal repression or suppression and
!Etiology
!Symbolic expression of intrapsychic conflict
!Behavioral reinforcement
!Secondary gains
!Serotonin/endorphin/abnormal perception of pain
delayed. primary gain = something immediate. cross the line to firbomyalgia,
chornic fatigue etc..treatment of fibromylagia is antidepressants.
there could be some biological predisposition and this is where you cross the line to fibromyalgia and chronic fatigue
PAIN DISORDER
!Pain can be anywhere (Headaches, back, face, pelvis, face,
vulvodynia, etc.)
!Pain can be posttraumatic, neuropathic, neurological,
iatrogenic, or musculoskeletal
!Importance of psychological factor
!Patients attributed all their anxiety and depressed mood to
their pain
!Most evolve to chronic, may lead to narcotic pain
medication addiction
genital pain is related to sexual trauma and is the reason not to have sexual intercourse because its is painful and unwanted
it can cause addiction
usually chronic and life long
!Differential Diagnosis
!Physical pain
!Other somatoform disorders
!Factitious or malingering
PAIN DISORDER
!Course and Prognosis
!Pain is usually chronic
!Improvement with elimination or management of psychological
distress
!Poor prognostic factors: long duration of pain/material gain
(disability)/substance abuse and passive attitude
!Treatment
dealing with somatizers is very difficult challenging and draining you will never cure
them they are always unhappy ull feel inadequate they will make you feel like your
not a good doctor they suck the life out of you and they cause countertransference